Community Employment Application

Name*
Email address*
Phone number*
Are you looking for help with*
- Obtaining employment
- Maintaining employment
Check all that apply
Date of birth*
Legal status*
- Emancipated adult
- Has a legal guardian
- Minor under age 18
Parent name (if under 18)
Guardian name (if applicable)
Address
Best days and times to contact you, and preferred method of contact
Primary diagnosis
Referral source (if any)
Do you receive any other ADEC services?
Have you applied for VR (Vocational Rehabilitation) services?
- Yes
- No
If you have a Medicaid Waiver, please list your case manager/company name and case manager's email.